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S AND Y C ONNER, P. T.

Proper Positioning to Prevent Hip Dysplasia

What is Hip Dysplasia?

Developmental Dysplasia of the Hip (DDH) Congenital Dislocation of the Hip (CDH) Developmental Dislocation of the Hip (DDH) Acetabular Dysplasia Hip Dislocation Hip Subluxation Loose hips

Where the femoral head has an abnormal relationship to the acetabulum and is the most common cause of arthritis in the hip

Anatomy Hip dislocation

Facts concerning the Hip Anatomy

Develops from a single mass of mesodermal tissue in the blastema (primary limb bud)

By the 10th week, joint space appears with movement possible

Stability is affected by The shape of the bony/cartilagenous surfaces

The action of the muscles

The integrity of the capsule and ligamentum teres

Causes of hip dysplasia

Acetabulum is shallow and under developed

The femoral head is out of socket Superior and anterior most common

Laxity of the Ligamentum Teres Most likely cause when lax

Cause not known- ? Maternal hormones

Acetabulum faces more forward and lateral than adults

Recent study in Japan, Kyushu University, found greater internal rotation of the innominate in DDH patients Increased acetabular anteversion and inclination angle therefore

decreased anterior and superior coverage of the femoral head

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Common facts

Approximately 1 out of 20 full term babies have some instability

2-3 out of 1,000 will require treatment Most escape detection until 13/14 years old when

pain/limp occurs due to early arthritis Unless treated early, it can lead to degenerative arthritis

in the adult 4x more common in girls At risk: family history foot deformity breech birth

Potential Signs

Hip clicks or pops

Limited ROM

Sway back

Shorter leg on that side

Uneven folds in the buttocks or thigh

Legs turned out

Wide space between legs

Pain (not common until 13/14 years old)

Asymmetry Asymmetry

Barlow-Ortolini

Barlow test Begin with legs in

abduction, adduct thighs with posterior pressure

Feel for click when it subluxes/dislocates

Ortolini test Begin with knees

adducted/flexed

Apply traction as you abduct

Treatment methods

Pavlik Harness

Hip abduction brace

Traction

Spica Cast

Closed reduction

Open reduction

Osteotomy

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Incidence varies by region

Studies of Native American Indians prior to 1950’s found very high incidence of hip dysplasia when cradle board used (10x higher) Decrease dramatically

after cloth diapers introduced

Research

Increased incidence in cultures where hips of newborns were commonly held in extension/adduction Northern Italy, North

American Indians, West Germany, Turkey, Japan

Forced passive extension/adduction (suspending by feet) can lead to initial dislocation

Research

Barlow found 1 in 60 had instability in 1 or both hips 68% became stable within 1 week

88% became stable by 2 months

Study of newborn pigs with hips extended for 6 weeks resulted in dysplasia of acetabulum, whereas maintained flexion led to normal acteabular development ( was reversible when legs released for 10 weeks)

Incidence in Japan was 1.5-3.5% before 1965.Decreased to .2% after eliminating swaddling with hips and knees

extended (Yamamuro T., Ishida K.)

Research (cont’d)

Swaddling is a greater risk factor than breech, family history or gender (Dogruel)

A 2008 study from Norway showed that more

than 90% of young adult cases cannot be diagnosed in childhood by current methods of screening

Carrying method

Decreased incidence in Africa where they carry babies on back with legs flexed/abducted (Salter,RB)

Swaddling benefits

Calming effects

Facilitated flexion

Soothing pain

Thermal regulation

Improved sleep patterns

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IHDI Position Statement

Swaddling infants with the hips and knees in an extended position increased the risk of hip dysplasia and dislocation. It is the recommendation of the International Hip Dysplasia Institute that infant hips should be positioned in slight flexion and abduction during swaddling.

Continued

The knees should also be maintained in slight flexion. Additional free movement in the direction of hip flexion and abduction may have some benefit. Avoidance of forced or sustained passive hip extension and adduction in the first few months of life is essential for proper hip development

Swaddle methods

Square Place baby supine with

head along top edge of blanket. Bend elbows up with hands toward face. Bring one side across chest and tuck under, then other side. Bring bottom of blanket up and tuck sides behind the trunk.

Square method

Swaddle methods

Diamond Place blanket in diamond

shape with top corner folded down. Put baby supine with head above top edge of blanket. Bend elbows up with hands toward face. Bring one side across chest, then bottom up, then other side.

Can also twist bottom of blanket and tuck under legs after bringing both side across.

Make sure hips can come up and out and allow room for movement

Diamond method

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Diamond twist Commercial Products

Should have loose pouch or sack, but not tight or confining

Should allow legs to flex /slightly abduct

Halo Sleep Sack Swaddle

Dandle-Lion Wrap

Kiddopatamus Swaddle Me

Follow the safe sleep standards

Commercial Products

Halo Sleep Sack Swaddle Place baby supine inside

device , zipped up. Flex elbows to bring hands toward face. Bring one side across and tuck under, then other side.

Allows for movement but does not facilitate flexion for preemies

Dandle-Lion Wrap

Place baby supine with head above top edge. Flex elbows to bring hands toward face. Bring short wing across then longer wing and attach velcro to back. Flex legs upward loosely and bring lower pouch up, attaching velcro tabs to back

Stretchy fabric allows for movement yet helps facilitate flexion for preemies

Dandle-Wrap Kiddopatamus

Swaddle Me Place baby in pouch

Brings hands toward mouth

Bring one flap across then other to velcro

Has small piece of velcroto bring pouch up slightly

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Bibliography

Bregjje E Van Sleuwen, Adele C Engelberts, Magda M Boere-Boonekamp, Wietse, Kuis, Tom W.J. Schulper & Monique P. L’Hoir, Swaddling: A Systematic Review, Pediatrics 2007; 120(4):e1097

Charles T. Price, MD, Richard M. Schwend, MD, Improper Swaddling a Risk Factor of Developmental Dysplasia of Hip, American Academy of Pediatric 2011; 32:9

Eli Peled, MD, Mark Eidelman, MD, Alexander Katzman, MD, Viktor Bialik MD, Neonatal Incidence of Hip Dysplasia Ten Years of Experience, Clinical Orthop Relat Res. 2008 April; 466 (4): 771-775

H. Dogruel, H. Alalar, O.Y. Yavuz, U. Sayli, Clinical Examination versus Ultrsonography in Detecting Developmental Dysplasia of the Hip, Int Orthop 2008, 33(3): 415-419

John H. Wedge, MD, M.J. Wasylenko MD , The Natural History of Congenital Dislocation of the Hip: A Critcal review, Clin Orthop & Rel Research 1978; 137: 154-162

Bibliography (cont’d)

Karen Rosendahl, Trond Markestad, Rolv TerjeLie, Ultrasound Screening for Dev Dysplasia of the Hip in the Neonate: The Effect on Treatment Rate and Prevalence of Late Cases, Pediatrics 1994; 94: 47-52

Katsumasa Ishida, MD, Prevention of the Development of the Typical Dislocation of the Hip, Clin Orthop Relat Res 1977; 126:167-169

Liu, W.F., Laudert, S., Perkins, B., MacMillan-York, E., Martin, S., & Graven, S. (NIC/Q 2005 Physical Environment Exploratory Group)2007; The Development of Infants in the NICU, Journal of Perinatology; 27: S48-S74

Robert B. Salter, MD, Etiology, Pathogenesis and Possible Prevention of Congenital Dislocation of the Hip, The Can Med Assoc Jour 1968; 98(20): 933-945

Yamamero T, Ishida K, Recent Advances in the Prevention, Early Diagnosis, and Treatment of Congenital Dislocation of the Hip in Japan, Clin Orthop Relat Res 1984 Apr; 184:34-40

www.hipdysplasia.org

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